Allen, Ronald D )2s0
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ronald D Allen Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/26/2021 87 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Hadley Town Street Address 11 Woodard Avenue,Hadley Town,New York 12835
p Manner of Death NINatural Cause ElAccident ❑Homicide Suicide ❑Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 George Siniapkin MD
Address
604 Palmer Avenue,Corinth Town,New York 12822
Death Certificate Filed District Number Register Number
City,Town or Village Hadley 4558 25
Burial Date Cemetery,Crematory or Facility Name
12/28/2021 Pineview Crematory
ElEntombment Address
ElCremation Queensbury Town,New York
EiDonation
Removal Date Place Removed
and/or , and/or Held
H Hold Address
0
a Date Point of
U) 11 Transportation
Q by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped,If Other than Above
a Address
Q
W
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/27/2021 Registrar of Vital Statistics Pauline G Smead(Electronically Signed)
(signature)
District Number 4558 Place Hadley, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H Z Date of Disposition /?aE 'I/Place of Disposition U)1 e V Ete,trI R�b
W
2 (address)
W
CC
N (section) (lot number) (grave number)
Name of Sexton or Person in Charge o remises - �A t i1 c'✓-' w oc,
(please print)
111 Title �'re - '
Signature >-
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b)
Receipt
ti
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#